Acute cardiac ischemia (ACI), including acute myocardial infarction (AMI) and unstable angina pectoris, is the leading cause of death in women in the US. Despite growing interest in ischemic (coronary) cardiac disease in women, little research has focused on women in the most common site of ACI initial evaluation and care: the emergency department (ED). Yet improving medical care quality and outcomes for ACI in women will require an understanding of gender's influence on initial ED presentation, diagnosis, triage, treatment, and outcomes. To be conducted by New England Medical Center's Center for Cardiovascular Health Services Research (CCHSR), this proposed project will take advantage of data on 17,500 patients (7,500 women, 10,000 men) presenting with chest pain or other symptoms suggestive of ACI from a currently- underway AHCPR-supported ED clinical trial being conducted by the CCHSR: the 10-hospital ACI-TIPI (Time-Insensitive Predictive Instrument) Impact Trial (ROl HS07360). Also to be used will be data on 7,554 patients collected in previous related CCHSR ED ACI predictive instrument trials between 1976-81 (NCHSR/AHCPR R01 HS02068). We will use these data to answer key questions in the care of women with ACI, in a series of five inter-related studies: STUDY I: Are women's ED presentations of ACI different from men's? STUDY II: Are there differences between women and men in the ED diagnosis and triage of patients with chest pain and other symptoms suggestive of ACI? STUDY III: Are there differences between women and men in the use of non-invasive and invasive treatments among patients presenting to the ED with ACI? STUDY IV: Are there significant differences between women and men in medical outcomes during the acute event and within 30 days following ED presentation with ACI? STUDY V: Have differences between women and men in their ED presentation, diagnosis, and/or triage for chest pain or other symptoms compatible with ACI changed over the past 10-15 years? In studying the impact of gender, these studies will also include analyses for primary and interaction effects related to patient sociodemographic features, ED presenting clinical features, physician type and training, hospital type and ED setting, health insurance type, and will include adjustments for patients' probabilities of having ACI as well as their likelihood of acute cardiac mortality. The detail of prospectively-collected data and number of patients available for this project with the resulting large statistical power (while savings the cost of the $1.8 million ACI-TIPI Trial data collection effort) and the experience of the CCHSR in over a decade of related studies of factors influencing the triage, treatment, and outcome of ED patients with ACI, provide this project with substantial promise of new and useful results.